My entire EMT class was a blur. The lessons were quick, the skills stations were chaotic, we had two chances to pass a test and if you didn’t pull off that magical 70% you were out! Go sell shoes! You don’t belong here with the road dogs. You’re not part of the elite. Before I knew it, 3 months had gone by and I was ready to sling and swath with the best of them. I was going to save lives, snatch grandma from the jagged jaws of death with nothing but a non-re breather and tube of glucose; I. WAS. READY. First call, diabetic, boom nailed it. Second call, intoxicated subject, bam knocked it out of the park. Third call, man lying on his porch covered in the blood he had started coughing up only minutes before, pale as paper, barely talking except for a gurgled “Help me” that I only heard over the screaming of his hysterical wife because I was close to his face. We went to move him to the cot and he threw up more blood than I had ever seen in my life all over his 5-year-old daughter, reared back and let out a yell that I could only relate to an animal going to slaughter, and promptly died. Every compression brought up more blood, every time my hands pushed on his chest I felt ribs breaking (and that no longer made sense because how are they still breaking if they’re all already broken), every time we stuck the suction catheter into his mouth the cannister filled higher and higher. The screaming from his wife had followed us and now threw panic into the box from the front seat, but it wasn’t just screaming anymore it was pleading and praying. She knew what was happening and she was helpless, we knew what was happening and we were helpless too, he was too far gone before we even pulled up. He was pronounced dead 5 minutes after we moved him from our stretcher to the hospital bed. Her screaming never stopped.

…...whoa……

I didn’t see the inside of that first aid building again for a month. I couldn’t sleep, I barely ate, I jumped at sounds if I was out in public and even in waking hours I could still hear that man’s wife screaming her throat raw if the room was too quiet. I drank. A lot. I’d still close my eyes and see his blood filled, gaping mouth with his lifeless eyes. I marched through every aspect of that call, taking blame for not doing better and wallowing in the trauma for weeks until finally a friend of mine on the squad reached out because I hadn’t been around. He asked me if I was ok and it was like someone opened a dam because it all came flooding out. He listened, he poured shots, and he listened more and in the end all he said was, “Sometimes people just die, you gotta move on if you’re going to help anyone else.” Toughen up kid or go sell shoes. The elite don’t need you if you can’t stand firm. This is the nature of the work, and if you are going to fall apart after every gruesome death then what good are you?

Why is this how we treat each other? Why is this how we treat ourselves? Again, this isn’t a thing that is isolated to just those of us on an ambulance. Police and fire, oh man, if you ever want to walk into a profession that is all about stifling down those dark sad feelings so you can get to the next tragedy then you have hit the jackpot. We eat our young habitually, and that mentality costs us dearly. It’s not money, time or training that we withdraw that cost from, its providers lives.

A survey conducted through CISD groups and CISM teams revealed that 37% of the participants had contemplated suicide following what is classified as a critical stress incident and 6.6% had actually attempted, both of which were miles above the CDC national average of those who fell into either category. The suicide attempts were a whole 5.1% above those civilians who attempted and survived nationwide. Whole numbers above the national rate!! The study from the Ruderman Family Foundation found police have 140 identified suicides in 2017 and firefighters had 103 suicides, both those numbers are 67% higher than line of duty deaths and up to 40% higher than the national average. The IAFF Center for Excellence just released a study of 1,027 retired and active firefighters; 8% had suicidal thoughts, 2% had made plans to commit, 5% had attempted, 4% had self-harmed but not attempted. Plus, those are just the ones that are either confirmed or reported as such. The mystery number has the potential to be so much higher. Those that attempted and succeeded are the numbers that are most disturbing, they’re not there because they lost their fight, and it’s a gap in the graph that should be most noted. These numbers should alarm you! These attempts or successes are representative of a gigantic rift in the system, AND they’re preventable.

First things first, lets differentiate between what PTSD is and what depression is. According to the American Psychiatric Association, depression is defined as “…feeling sad or having a depressed mood, loss of interest or pleasure in activities once enjoyed, changes in appetite-weight loss or gain unrelated to dieting, trouble sleeping or too much sleep, increased fatigue, feeling worthless or guilty..” and the list goes on. I, for one, am diagnosed with cyclical depression. I have good days and bad days, I get up fine some mornings and some days I can’t shower because I’m not worth being clean. I have been shown how to recognize when a cycle is coming on and how to talk about it. I’m managed with medication and I see a therapist. I’ll tell you, depression is a total mental ass kicking, but it is NOT PTSD.

The National Institute of Mental health defines PTSD as “…a condition that occurs after a traumatic event, either on going (chronic) or short term (acute). Diagnosis criteria includes: at least one re-experiencing symptom, at least one avoidance symptom, at least two arousal and reactivity symptoms, at least two cognition and mood symptoms for a month or more.” These symptoms are described as flashbacks where the traumatized relives the trauma over and over again in their mind, bad dreams and frightening thoughts, being on edge or easily startled, angry mood swings, negative thoughts of oneself or the world and distorted feelings of guilt or shame. My husband, a 15 year firefighter and EMT, has chronic PTSD and there has been more than one occasion I’ve had to wake him from nightmares and wait for him to stop screaming. We eat in a crowded restaurant and he’s got to be in the chair that’s facing the door so he can see the room. He takes everything that happens in a normal day to day as a reflection of something he did wrong. He has had his world view changed by a series of events that he can’t remember completely.

Depression and PTSD share common symptoms, but they are NOT the same.

Besides the symptoms, the difference between the two conditions is simply put, physical. A traumatized brain changes physiologically while a depressed brain tends to remain the same just with less chemical receptors. MRI images show that a traumatized brain has areas that control feelings or emotions not functioning or functioning to a lower extent. Brains, chemicals or both the result is the same. Anxiety, depression, uncontrollable thoughts; they’re all relentless and they’re typically subtle and silent.

So, what’s the point, now that we’ve had our science lesson? We have all had someone touched by either of these conditions. Let’s not beat around the bush, by the time you’re done with this sentence there will probably be a name that pops into your head of someone who committed suicide and it was a shock. No one saw it coming. I’ll tell you why: Stigma. This standard of mental toughness that demands we walk into tragedy to earn a paycheck, and never take any kind of emotional baggage away from it. Here’s another level to that, if you do come forward your ability to perform your job is put into question. Maybe not on paper but your reputation is shot. Clearly you can’t be a competent provider of any service if you are also dealing with your depression or your trauma with medication or talk therapy. Clearly somehow these conditions make you more of a risk to the public than they do to yourself.

You know what is awful about PTSD/depression? When you have a normal, human reaction to coding a baby or a stressful CHF patient or a drunk calling you names, the condition tells you that it makes you a bad person and you’re not worthy of help. Know what is awful about the current culture on mental health in public service? We tell each other that the condition is right.

It’s getting better though. There’s this wave of acknowledgement sweeping the streets that is slowly destigmatizing mental illness. There’s organizations that work solely on improving awareness, setting up hotlines for those in crisis, people who work in our field manning the phones so that there’s at least a voice on the other end that knows how we work and what we do. These strides are phenomenal, truly revolutionary, and will be shamelessly plugged at the end of this piece. Still, 37% just thinking about suicide. It’s a scary place to be. I’ve had days where the depression and anxiety clashing in my brain all at once lead me to those thoughts. They were all consuming, over taking even happy thoughts or actions. I’d be in the middle of doing one thing and the overwhelming thought in my head would be of how I could kill myself. Gruesome images, feelings of worthlessness, sadness because under all the horror was the condition telling me that it didn’t matter how it was done. No one would care anyway. I didn’t want to die, but I felt like I had to. I kept telling myself that it’s a selfish act and all the other cliché phrases we see on “get help” billboards but in the moment, it felt like something resembling relief. The one thing I couldn’t do was call one of those hotlines. I couldn’t talk to a stranger about this. The depression told me I would be judged and shamed, my worthlessness confirmed. I worked through it, I had family that was able to get me to a hospital, but it makes you think; how else can we make this better?

I’m an education advocate. I truly think that how we educate our students is how we shape the face of the profession. I read an article by Julia Smith, RN in JEMS a while back. She’s an educator that had a student who climbed the ranks reach out to her when his calls got the better of him. He told her he didn’t know how to deal with these feelings and her point was that we barely introduce the concept of mental health when we have their play doh minds in our hands. That’s a huge disservice. It’s only a chapter in the textbook, four pages long. Well being of the EMT. I think they cover more about nutrition than they do about dealing with the residual screaming you hear when you try to sleep. Don’t eat too much, exercise, don’t do bad things if you start to feel bad. Summary complete. She makes the point that it’s just not enough.

The first thing people notice about a person’s motive when they’ve killed themselves is all the changes that went unnoticed. All the behaviors that shifted just off center that told the whole story and warned about how it was going to end. Why isn’t this part of our curriculum?

Here’s an idea; it’s not a lecture, it’s a workshop. Gather your students and their families, include their friends, roommates, whoever and have an honest to goodness talk about why people in our profession commit suicide. Facilitate the conversation about how stressful the job can be, how feeling things about the bad calls is not only normal but it doesn’t make you weak, how what we do and what we see will come home with you no matter how hard you try to leave it at the door. This lets the student know what they’re walking in to once they walk out of your doors and it lets the family and friends know that there are going to be things their person goes through that they should be aware of. It also lets the student know that someone else in the room is going to get it when it happens to them. You’re giving them a support system before they step on the trucks.

Break for lunch, take a breather, this isn’t light stuff, but the solution is what comes next.

We’ve started the process of letting our people know what to expect and that there are people who get it, now give them tools to work through the crisis. Help the student understand how they react to bad stressors and facilitate the discussion between them and their families. What do they do that they don’t notice? How do they act when they feel scared or depressed that their families don’t understand. Once you open that dialogue, give them ways to replace those bad behaviors with good ones and see how they fit. Arm the support system with ways to reach the student when they are deep in their own despair, give the student a safe place to reach out to when the depression or PTSD says they shouldn’t talk about it at all. Finally, give them ways to come down from a crisis. Physical stimuli through breathing or yoga, workouts that will expel some of the energy pent up from the anxiety these conditions produce, mindfulness practices so they can feel quiet and safe without listening to the voice in their heads that tell them they’re all wrong.

As they walk out the door, hand them the phone numbers to the anonymous help lines offered so they always have options outside of those they’re with that day. Include a list of numbers your instructors feel comfortable giving out in case neither of their other options feel good. We bring them into this world, we should be there to catch them if they need us. Hand them to their new support system too for when they don’t know how to help anymore.

Safety net, introspection, coping mechanisms and a destigmatized view of mental trauma and illness. This is the chance we have to create a new wave of self-aware providers.

Let’s also tend to those already in the field. Sure, its great to start with the students who are open minded and willing to talk, but that doesn’t mean we are releasing them into a world ready to follow suit. I was speaking to a friend of mine who brought up the point that for anyone she knew, for however long that was, she still wouldn't know how to tell if they were going through something serious or if they were considering something dangerous. For us, as providers, we walk in a room and are quick to determine if something isn’t right with a stranger; Sick/Not Sick, but we are bad at introspection. We must therefore rely on our peers to see the things we may be in a bad spot to see ourselves.

AFSP (American Foundation for Suicide Prevention) offers courses on how to assess a person for suicidal risk, how to talk to them even if they feel uncomfortable talking about it, and how to get them help. SAVE(Suicide Awareness Voices of Education) works within communities and work places to not raise awareness for the signs of suicide. Both organizations will train you in the art of identifying suicidal thoughts or actions in your peers and applying methods of prevention while getting people to places that will help them heal. These organizations often do that training for free in exchange for volunteer services laid out by each one’s terms individually. That’s what we do on our day to day, but we do it for strangers! Why can’t we do that for our friends and coworkers?

Being stuck in your own head, in a place that tears you down for doing what you are called to do, is the definition of hell itself. Its exhausting to put on a smile while your inner voice tells you you’re worthless and no one cares if your live or die. It’s perilous to walk that fine line between needing to talk but feeling like you’ll be judged if you do. In the end, it’s a losing battle. 37% of providers surveyed have considered the option of suicide viable. 37%. Five times the national average have tried. Everyone knows someone who has succeeded. The memes going around after the recent celebrity suicides calling for us to check on each other have merit. We have to stop seeing a person in pain as a burden if we want to see that 37% go down, and that’s not something that gets turned off like a switch. Each one of us who has listened to the screaming in our own heads has 3 choices; take up the responsibility to change that number, carry the caskets of those we have left behind or go sell shoes.

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